A resident with depression and anxiety, who was cognitively intact per a recent MDS, received a 30-day written Notice of Intent to Discharge stating that discharge to another LTC facility was necessary because the facility could not meet the resident’s needs. Although the facility’s policy required that such discharge notices be provided to the Office of the Long-Term Care Ombudsman so the resident could exercise appeal rights, there was no documentation that the notice was sent to the Ombudsman. The resident reported that the Ombudsman’s office told him they had not received the notice, and the Ombudsman confirmed in interview and email that no notice was received. The Assistant Administrator stated that he or a designee typically faxed such notices to the Ombudsman but could not produce any documentation showing this was done in this case.
A resident with encephalopathy, vascular dementia with behavioral disturbance, TIA, alcohol abuse, and wandering was transferred twice from the facility to the hospital, but the facility did not provide the required written notice of intent to transfer and/or discharge to the resident or the resident’s representative, nor did it send a copy of the notice to the State LTC Ombudsman as required by its own transfer/discharge policy. Review of the medical record showed no such documentation, and the Director of Social Services confirmed that no written notices or Ombudsman notifications could be produced.
The facility did not provide written transfer and bed-hold notifications or notify the Ombudsman when several residents, including those with cognitive impairment or legal representatives, were transferred to the hospital. Record review and staff interviews confirmed the absence of required documentation for these notifications.
Three residents who were alert and oriented were discharged without being provided with the required Notice of Intent to Discharge, and the Office of the State Long-Term Care Ombudsman was not notified as mandated. Facility staff interviews confirmed that discharge notices and notifications were not issued for short-term stay residents, contrary to policy and regulatory requirements.
The facility did not provide required written transfer/discharge and bed hold notices to residents and their representatives during multiple hospital transfers. Despite residents having complex medical conditions and being transferred emergently, staff confirmed that the necessary documentation was not completed or present in the records, as required by facility policy.
A resident with complex medical needs was transferred to the ED without essential clinical documentation, including the MOLST, Health Care Proxy Form, and Hospital Transfer Form. Only a face sheet and medication list were sent, and no nurse-to-nurse report was provided. Facility staff confirmed that required transfer protocols were not followed, and the ED had to contact the facility later to obtain necessary information.
The facility did not provide required written transfer/discharge and bed hold notices to three residents, including individuals with significant physical and cognitive needs, during multiple hospitalizations. The Social Worker confirmed that these notifications were not completed when she was not present.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account